Open Journal of Stomatology, 2011, 1, 1-6 OJST
doi: 10.4236/ojst.2011.11001 Published Online March 2011 (
Published Online March 2011 in SciRes.
Evaluation of stress among 100 Moroccan orthodontists
Lahcen Ousehal1, Laila Lazrak2, Karima Hassani3
1Professor of Orthodontics, Department of Orthodontics, Faculty of Dentistry, Casablanca, Morocco;
2Resident, ODF Service, Faculty of Dentistry, Casablanca, Morocco;
3Student Graduate (MS), Faculty of Dentistry, Casablanca, Morocco.
Received 3 March 2011; revised 16 March 2011; accepted 18 March 2011.
Stress is associated with many professions including
dental surgery. It has been the subject of several
studies. However, its evaluation in orthodontics has
not been sufficiently studied. Some studies that have
described the stressful aspects of dentistry have re-
ported the involvement of orthodontists, but no stud-
ies have been conducted in Morocco. The purpose of
this study is to evaluate professional stress in ortho-
dontics in Morocco. We conducted a descriptive and
sectional study through a survey distributed to one
hundred private orthodontist practitioners in Casa-
blanca, Morocco. Stress signs were observed in 44%
of the orthodontists. The most prominent factors of
stress in orthodontics are related to patients and time.
Experience of practitioners has been identified as the
only factor significantly influencing their perception
of stress. Thus, clinical competence and proper man-
agement of practice are the best ways to deal with
daily stress in orthodonti c pr actice.
Keywords: Orthodontics; Stress; Time Management
Dental work is known to be both physically and men-
tally demanding, which exposes the dentist to stress.
Several studies have shown that dentistry [1,4,5] gener-
ates more stress than other professions because of the
nature and the working conditions of dentists.
The effects of professional stress have been well re-
ported; in fact, several diseases have been linked to pro-
fessional stress namely hypertension, disease of the
coronary artery, alcoholism, drug addiction and suicide.
The purpose of this study is to assess the prevalence
of stress among orthodontists, to identify the most
stressful situations and the factors most often associated
with this stress.
We conducted a cross-sectional and descriptive study
with dentists practicing orthodontics in Casab lanca.
2.1. People and Place of the Study
Inclusion criteria:
1) Practitioners with a degree in orthodontics.
2) Practitioners who have their offices in Casablanca.
Exclusion criteria:
1) Practitioners who have not completed the entire
On the list of orthodontists in Casablanca, a total of
116 were identifi e d.
Ten orthodontists did not answer because of:
1) 2 false addresses
2) 1 orthodontist does not practice orthodontics any-
3) 4 orthodontists have refused to participate in the
4) 3 orthodontists were on leave
Thus, the sample was represented by 106 orthodon-
tists; 86% of orthodontists in Casablanca have partici-
pated in the study.
The study was conducted using a survey comprising
78 questions, administered anonymously to orthodontists.
Some have responded the same day, others preferred to
complete it later. The latter were given a phone number
for further e xplanations or inf ormation.
The survey consisted of 3 main parts:
1) The first part consisting of the assessment of stress
and its impact on health.
2) The second part comprising the potential factors of
stress and the practitioners’ opinion of stress.
3) A third part asking for general information of prac-
2.2. Analysis of the Questionnaire
Professional stress has been evaluated using a list of
potential stress factors; a total of 66 factors were in-
cluded in the study. These were divided into six catego-
ries: patient, staff, time, income, reference and work.
These categories were based on the classification system
L. Ousehal et al. / Open Journal of Stomatology 1 (2011) 1-6
presented by Cooper et al..
Orthdontists were asked to indicate the severity of
each “stressful” situation, and the frequency of its oc-
The severity was classified using a Likert-type scale
(ref) with 5 scores from a scale 1: not stressful to 5: very
Scores of severity of each situation were calculated to
determine the most stressful aspects in orthodontic prac-
The frequency was recorded using a five-point scale; J:
Never A: Rarely, M: Monthly, H: Weekly, Q: Daily
The score of frequency of each situation was calcu-
lated to determine the most common factors of stress in
orthodonti c practice.
We also asked the orthodontists to assess the stress of
orthodontic practice usin g a scale ranging from 0 to 100.
This var iable was consid ered as the overa ll score of pro-
fessional stress.
The survey also included information on person al and
professional data of the practitioner: age, sex, marital
status, years of practice and type of practice. Six addi-
tional questions were included in the questionnaire to
assess the prevalence of stress and its impact on health.
One investigator was responsible for this study.
2.3. Statistical Analysis
The statistical analysis was performed using SPSS®
(version 17.0, 2008)
Of the 106 questionnaires, 100 were used which repre-
sented a response rate of 94%.
3.1. Sample Description
Our sample consisted of 31 women (31%) and 69 men
(69%) (Table 1).
Table 1. Distribution according to age and years of practi ce.
Man Woman Mean SD
N 69 31
25-35 26 39
35-45 5 19 Age
45-55 0 8
37.7 10.3
1-10 27 49
10-20 04 18 Years
20-30 00 02
12.3 10.2
Table 2. Prevalence of stress in the sample.
Sex Stressed No stressed
Women 19 12
Men 25 44
3.2. Evaluation of Potential Factors of Stress
Ranking of the most stressful situations based on the
average severity scores (Table 3).
The analysis of the situation revealed 22 cases of 67,
receiving a severity score greater than or equal to 3.0.
The most stressful situation was dissatisfaction of the
patient towards the care received, with an average of
4.04 and a standard deviation of 0.89.
The situation with the lowest severity score was diffi-
cult y to communicate with staff, with an average of 3.02
and a standard deviation of 1.14.
Classification of situations most often stressful based
on average frequency scores (Table 4).
Only the upper mid dle or equal to 3.0 were pr esented.
The analysis of these stressful situations indicated that
20 cases were a mean score of frequency greater than or
equal to 3.0.
The most frequent situation was the treatment of adult
patients; it has received an average of 4.29 and a stan-
dard deviati on of 1.09.
The situation with the lowest score was the frequency
of patients coming late or missing the appointment, with
an average of 3.00 and a standard deviation of 1.24.
Ranking of the most frequent and the most stressful
situations (Table 5).
The most stressful situations and the most frequent
ones were those with average score of severity and fre-
quency greater than or equal to 3.0.
They were considered the most interesting factors of
stress in the orthodontic practice.
This is due to the fact that those situations are the ones
that are considered stressful by most orthodontists and
occur more than once per month.
The analysis of all of these situations has classified 7
situations in which scores of frequency and severity are
greater than or eq ual t o 3.0.
Ranking of the six categories of stress factors (Table
Factors of stress were divided according to the classi-
fication of Cooper in six categories: patient, staff, time,
income, reference and work.
The average scores of these different categories were
calculated using a severity scale.
The category with the highest mean score of stress
was related to the factor “patient”, with an average se-
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L. Ousehal et al. / Open Journal of Stomatology 1 (2011) 1-6 3
Table 3. Ranking of the most stressful situations based on the average severity scores*.
Ranking Mean SD
1. Dissatisfaction of patients vis-à-vis the care received. 4.04 0.89
2. Treatment of adult patients. 3.83 1.04
3. Difficulties communicating with patients. 3.74 1.02
4. Pressure from patients to end the treatment. 3.58 1.04
5. Treatment of cases with a poor prognosis. 3.52 1.01
6. Execution of clinical tasks on difficult or uncooperative patients. 3.51 1.14
7. Patient coming late or missing appointments. 3.49 1.05
8. Motivation of patients with poor hygiene. 3.47 1.00
9. Dealing with unrealistic e x p ec t a t i ons of patien t s . 3.39 1.34
10. Patient late or miss their bonding session. 3.31 1.03
11. Patients with broken b races. 3.28 1.22
12. Having trouble winning patients ’ trust. 3.19 1.43
13. Legal disputes with patients . 3.16 1.06
14. Being overworked. 3.10 1.05
15. Acceptance of treatment outcome with compromise. 3.09 1.19
16. Being late. 3.08 1.32
17. Lack of payment of fees. 3.07 0.99
18. General practitioners challenging case management. 3.06 0.89
19. Inability to meet my o wn expectations. 3.05 1.12
20. Competition from other o r th o d ontists. 3.04 1.43
21. Long hours of work. 3.03 1.00
22. Difficulty to get along with staff. 3.02 1.14
*Classified from 5 (most stressful) to 1 (stressful). Only averages greater or equal to 3 were considered.
Table 4. Classification of situations most often stressful based on average frequency scores*.
Classement Moyenne Ecart-type
1. Treatment of adult patients 4.29 1.09
2. Motivation of patients with poor hygiene. 4.12 1.07
3. Motivation of patients with poor hygiene. 4.09 1.33
4. Difficulty to get along with staff 3.89 1.14
5. Patients with broken braces 3.79 1.04
6. Difficulties communicating with patients 3.66 1.14
7. Patient coming late or missing appointments 3.52 1.45
8. Treatment of cases with a poor prognosis. 3.48 1.22
9. Long hours of w ork 3.39 1.45
10. Constant time pressure 3.28 1.22
11. Difficult work conditions 3.21 1.15
12. Emergency patients 3.19 1.34
13. Awareness that treatments are not permanent. 3.17 1.06
14. Overwork 3.10 1.33
15. Try to keep a progr a m. 3.08 0.89
16. Patients transferred to another practice in your a rea 3.05 1.22
17. Patient express ing your fees are too high. 3.03 1.43
18. Obligation to train new assistants. 3.02 1.16
19. Difficulty to get along with staff 3.01 1.45
20. Patient comi ng late or missing appointments 3.00 1.24
*Classified from 5 (most stressful) to 1 (stressful). Only averages greater or equal to 3 were considered.
opyright © 2011 SciRes. OJST
L. Ousehal et al. / Open Journal of Stomatology 1 (2011) 1-6
Copyright © 2011 SciRes.
Table 5. Ranking of the most frequent and the most stressful situations.
Facteur stressant Facteur stressant Facteur stressant
1. Treatment of adult patients 3.83 4.29
2. Difficulties getting a long with pat ie n t s. 3.74 3.89
3. Acceptance of treatment outcome with compromise. 3.09 3.48
4. Patient late or miss t heir bonding se ssion 3.31 3.52
5. Patient coming late or mi s s i n g t h e appointment. 3.49 3.00
6. Treatment of cases with a poor prognosis. 3.52 3.48
7. Long hours of w ork 3.03 3.39
Table 6. Ranking of the six categories of stress factors.
Type of stress factor # of factors in type Severity average Standard deviation
Factors related to the patient 17 3.74 0.78
Factors related to time 7 3.02 0.87
Factors related to staff 8 2.67 0.66
Factor related to work 19 2.45 0.98
Factor related to income 10 2.43 0.87
Factors related to t ransfers 6 2.42 0.75
*Ranked from 5 (very stressful) to 1(non stressful).
5. DISCUSSION verity of 3.74 and a standard deviation of 0.78. Followed
by the time factor that has been classified as second
category related to stress with an average of 3.02 and a
standard de v i a tion of 0.87.
This study was exhaustive because it concerned all the
orthodonti st s o f Casa bl anca.
The study showed a high rate of response, 94.3%.
The category with the lowest average score of stress
was related to factor “transfer”, with an average of 2.42
and a standard deviation of 0.75. 5.1. Overall Professional Stress among Ortho-
VARIABLES RELATED TO STRESS The prevalence of stress among dentists has been esti-
mated to 60% in the United Kingdom (MYERS1), 59.7%
in Denmark (Moore and coll [2]), and 48% depending
Vanagas and coll [3] (Lituania).
The overall score of stress was used as the dependent
variable in a multiple reg ression analysis. The prevalence of stress among orthodontists in Casa-
blanca is less important than in other countries, since it
has been estimated to 44%. These results demonstrate
that the phenomenon of stress is present in orthodontic
The remaining variables: age, sex, and duration of ex-
ercise were included as independent variables.
The analysis of the correlation by multiple regression
of variables related to stress indicated the duration of
exercise as the only characteristic that was positively
related to stress (p < 0.005). Other characteristics were
negatively associated with stress (p > 0.005).
But this result is still high er compared to other studies
such as in Holland, where only 13% to 16% of dentists
suffer from professional stress (Gorter and coll [4]).
5.2. Factors of Occupational Stress among Or-
Table 7. Correlation and multiple regression of different vari-
ables related to stress*.
Variable related to
stress Nature of the correlation P-value
Global stress Negative 0.001
Age Negative 0.005
Sex Negative 0.008
Experience Positive 0.004
A similar study was conducted among Canadian ortho-
dontists [5]. The most frequent factors of stress were
almost identical in bo th studies. These factors include the
treatment of adult patients, patients coming in late and
motivating patients with poor hygiene and/or decalcifica-
Too much work, the difficulty to agree with staff and
with patients was also among the most frequent factors
of stress. These were also reported as major stress factors
*Overall R² = 0.345.
L. Ousehal et al. / Open Journal of Stomatology 1 (2011) 1-6 5
in an American study [6].
Regarding the most stressful aspects, the three factors
most strongly affected were: patient dissatisfaction
vis-à-vis the care received, treatment of adult patients,
and the lack of communication with patients. Compared
with the Canadian study [5 ], only the first factor has been
ranked among the top three most stressful factors. The
remaining factors are: the execution of clinical tasks on
difficult or uncooperative patients that have fallen be-
Other factors of stress that are similar to the Canadian
[5] study are: patients late or missing their bonding ses-
sions, patients with broken appliances, the constant
pressure of time, acceptance of treatment outcome with
compromises, treatment of cases with a poor prognosis,
and the medico-legal cases.
Many similarities were also observed between the re-
sults of this study and those reported in general dentistry
that also made reference to the factors leading the most
to stress, mainly: the dissatisfaction of patients, patients
with difficult or uncooperative patients and emergency.
Two situations have been reported as being stressful in
general dentistry, but have not proven highly stressful in
orthodontics, these included the perception of the practi-
tioner as a source of pain and frequent decision making.
However, many other situations have been reported as
stressful in the orthodontic population, but they are not
common in studies of general dentistry. These include:
pressure from patients and/or parents to remove the de-
vices before the end of treatment, the awareness that
treatment is not permanent, general practitioners chal-
lenging case management, and deal with unrealistic ex-
pectations of patients. This suggests that stress in ortho-
dontics is associated to the particularity of the specialty
in addition to the general characteristics of dental prac-
Despite the many similarities between the results of
the study and the Canadian study [5], analysis of the
most concerned factors in orthodontics showed a big
The four largest factors of stress among Canadian or-
thodontists were those related to time management [5,8 ].
Orthodontists in Casablanca ranked this factor second
after the factor “patient”.
Indeed, treatment of adult patients, the difficulty of
communication with patients require more attention and
therefore more “work hours”, just as patients coming late
or missing their meeting bonding and patients missing
their appointments also generate disturbances at the level
of “hours”.
So all these factors cause an increase in working hours,
leading orthodontists to be under stress.
This result is consistent with that of Vander Hulst [9]
which proved an association between long working hours
and adverse health manifested by fatigue, stress and gen-
eral diseases such as diabetes and cardiovascular disease.
5.3. Factors Affecting the Occupational Stress in
Although the difference between groups was low, analy-
sis of the scores of the six factors of stress ranked the
factor in relation to the patient first of the list, followed
by the one related to time.
A similar result was reported by numerous foreign
studies like those conducted with Lithuanian [10] and
South Korea [11] dentists.
General dentistry Doctors [10-12] also ranked these
two factors as most importa nt .
The study on Canadian orthodontists [5] revealed
similar results, and classified these two factors as the
main source of stress.
These results showed the importance of these factors
and suggest that orthodontists who want to reduce stress
should first improve their management skills with their
patients and that of time of their work.
5.4. The Role of Various Personal Characteristics
and Practice on Stress in Orthodontics
Personality and indiv idual differences are known to have
important influences on the stress response. Indeed,
marked differences were observed in response to the 66
potential stress factors. Each case was classified as “very
stressful” by at least one orthodontist and not as “stress-
ful” by at least one other. Similarly for frequency, since
facing the same situation at least two orthodontists have
responded diff erent l y.
But these influences played a larger role in the estima-
tion of stress in orthodontics, whose answers have in-
cluded almost the entire scale and have reached 90 points
on the scale of 100 points.
In our study, age, sex and years of practice have been
described in a final regression model to explain some of
the variation of occup a tional stress.
These characteristics have been reported as affecting
the relationship of stress in global dentistry [7] and or-
thodontics [5].
The duration of exercise was reported as the only fac-
tor significantly associated with stress according to the
regression model. This suggests that as and when the
duration of exercise increases, stress decreases.
So it is reasonable to assume that orthodontists prac-
ticing for several years become more knowledgeable and
more aware of stress, and therefore more likely to take
steps to manage it.
It is interesting that the age and sex were not signifi-
cant in our study, although there is a possible interrela-
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L. Ousehal et al. / Open Journal of Stomatology 1 (2011) 1-6
Copyright © 2011 SciRes.
tionship between these two factors and stress in other
studies [13].
Overall, this regression model could not exp lain all the
variation in scores of job stress.
This suggests that there are other factors such as per-
sonality that may influence stress.
What we can conclude at the end of this survey is that
there is a wide variation in the assessment of potential
stress factors and the overall estimate of occupational
stress in orthodontics.
Similarly, other factors seem to have a greater effect
on the stress than the characteristics assessed by this
Several limitations should be taken into account when
interpreting the results of this study. Notably, the fact that
the results reflect only the data collected by question-
naire and low sample size must be increased and diversi-
Thus, any longitudinal studies are strongly needed to
examine changes in environmental factors at work.
In our work, we studied th e so ur ce, th e frequ e nc y and the
severity of stress experienced by orthodontists.
Marked differences were found between orthodontists
in Casablanca in the evaluation of factors of stress and
the overall estimate of occupational stress in orthodon-
Thus, 44% of orthodontists suffer from chron i c st r ess.
The most relevant factors of stress to orthodontic prac-
tice based on high average severity and frequency are
factors related to the patient (3.74 0.78) and those re-
lated to time (3.07 0.87).
The analysis of the correlation by multiple regression
of variables related to stress identified only the duration
of exercise as a factor significantly influencing the per-
ception of stress. Indeed, the previously installed ortho-
dontists feel less stress compared to younger people in
the profession.
Clinical competence and the proper management of
orthodontic practice remains a real cornerstone for re-
ducing stress in daily orthodontic practice.
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